UnitedHealth Group Rotten Score Breakdown

On June 20, 2024, the New York Attorney General announced a settlement requiring UnitedHealthcare of New York, part of UnitedHealth Group's UnitedHealthcare insurance business, to pay a $1 million penalty and reimburse affected consumers after an investigation into contraceptive coverage. UnitedHealth Group identifies UnitedHealthcare as one of its two principal operating businesses. The Attorney General's Health Care Bureau opened its investigation after a Brooklyn patient complained that a UnitedHealthcare Oxford plan denied coverage for an oral contraceptive. The patient's appeal was rejected, and the plan required prior authorization or step therapy—requiring the patient to try alternatives first. The Attorney General stated that the resulting denial and delay forced the patient to go without the prescribed birth control and violated New York's Comprehensive Contraceptive Coverage Act. That law requires health plans to cover FDA-approved contraceptives without copays, restrictions or delays. Under the settlement, UnitedHealthcare agreed to pay the $1 million penalty, ensure that its New York plans provide legally required contraceptive coverage, and train staff involved in contraceptive claim approvals. It also agreed to reimburse consumers for out-of-pocket contraceptive costs, plus 12 percent interest. The reimbursement provisions cover eligible payments dating from June 1, 2020 onward. Primary source — Office of the New York Attorney General: https://ag.ny.gov/press-release/2024/attorney-general-james-announces-settlement-unitedhealthcare-failing-provide Corporate relationship — UnitedHealth Group: https://www.unitedhealthgroup.com/uhg/businesses.html This record concerns the conduct and settlement obligations of the New York UnitedHealthcare insurance entity. It is attributed to UnitedHealth Group through the UnitedHealthcare operating business; it should not be generalized to every UnitedHealth plan or subsidiary.

OptumRx Inc., part of UnitedHealth Group's Optum business, agreed on June 27, 2024 to pay $20 million to resolve U.S. government allegations concerning opioid prescriptions filled by its former Carlsbad, California mail-order pharmacy. The corporate relationship is documented on UnitedHealth Group's business page, which identifies Optum Rx as one of the group's operating businesses. The U.S. Department of Justice said the settlement followed a Drug Enforcement Administration investigation into prescriptions filled between April 2013 and April 2015. The government alleged that OptumRx filled certain opioid prescriptions combined with benzodiazepines and muscle relaxants—sometimes called “trinity” prescriptions—even when the combinations raised red flags suggesting possible abuse, diversion or a lack of legitimate medical purpose. According to the DOJ, these combinations presented a significant risk of harm and pharmacies were required to resolve such warning signs before dispensing the controlled substances. The DOJ expressly stated that the resolved claims were allegations only and that there had been no determination of liability. The settlement therefore should not be described as a conviction or admission by OptumRx. The agency also reported that OptumRx had introduced enhanced opioid-dispensing protocols beginning in 2017, strengthened concurrent drug-utilization review procedures, and closed the Carlsbad mail-order pharmacy during the investigation. Primary source — U.S. Department of Justice: https://www.justice.gov/archives/opa/pr/optumrx-agrees-pay-20m-resolve-allegations-it-filled-certain-opioid-prescriptions-violation Corporate relationship — UnitedHealth Group: https://www.unitedhealthgroup.com/uhg/businesses.html This is attributed to UnitedHealth Group through its Optum Rx operating business. The record concerns a government settlement of Controlled Substances Act allegations, not a finding that every Optum or UnitedHealth operation participated in the conduct.

In September 2024, the U.S. Federal Trade Commission filed an administrative complaint against UnitedHealth Group's pharmacy benefit manager Optum Rx, along with CVS Caremark and Cigna's Express Scripts, alleging that the three dominant PBMs used anticompetitive and unfair rebate practices that artificially inflated insulin list prices, restricted access to lower-list-price insulin products and shifted costs onto vulnerable patients. The FTC said the three companies collectively administer approximately 80% of all prescriptions in the United States, giving them enormous influence over which medications are included on health-plan formularies and the prices patients ultimately face. Federal Trade Commission – FTC sues Optum Rx, Caremark and Express Scripts over insulin practices: https://www.ftc.gov/news-events/news/press-releases/2024/09/ftc-sues-prescription-drug-middlemen-artificially-inflating-insulin-drug-prices FTC – Insulin PBM case and proceeding: https://www.ftc.gov/legal-library/browse/cases-proceedings/221-0114-caremark-rx-zinc-health-services-et-al-matter-insulin According to the FTC complaint, Optum Rx and the other PBMs created a system in which their financial incentives favored drugs carrying high list prices and large manufacturer rebates. PBMs negotiate rebates with drug manufacturers and determine which medicines receive preferred placement on formularies used by health plans. The FTC alleged that this created what it described as a “chase-the-rebate” strategy: manufacturers had an incentive to increase insulin list prices so they could provide larger rebates and fees in exchange for favorable formulary placement. The FTC alleged that insulin list prices increased dramatically as this system developed. For example, the agency said the list price of Eli Lilly's Humalog increased from approximately $21 in 1999 to more than $274 by 2017, an increase exceeding 1,200%. The FTC did not attribute that entire increase solely to Optum Rx and specifically noted that insulin manufacturers also played a potentially culpable role in increasing prices. The FTC further alleged that even when manufacturers introduced lower-list-price insulin products, Optum Rx and the other PBMs systematically excluded some of those products from heavily used commercial formularies in favor of essentially equivalent products carrying higher list prices and larger rebates. FTC – Public administrative complaint: https://www.ftc.gov/system/files/ftc_gov/pdf/612314.2024.11.26_part_3_administrative_complaint_-_revised_public_redacted_version.pdf The alleged system was particularly harmful to patients whose deductibles or coinsurance were calculated using the insulin's unreduced list price. While health plans and PBMs could benefit from manufacturer rebates, some patients did not receive those rebates directly at the pharmacy counter. The FTC alleged that certain patients therefore could pay more out of pocket for insulin than the entire net cost of the drug after rebates to the commercial payer. The agency alleged that the PBMs knew their rebate and formulary practices could produce this result but continued the practices. The FTC also pointed to the broader affordability consequences of rising insulin prices. According to the agency, by 2019 approximately one in four insulin patients was unable to afford the medication. Because insulin is medically necessary for people with certain forms of diabetes, the FTC argued that patients could not reasonably avoid the harm simply by deciding not to purchase the drug. Company response: Optum Rx has strongly disputed the FTC's allegations. In its formal answer to the complaint, Optum Rx denied that its conduct caused insulin to become unaffordable for its members and stated that nearly all of its clients' members have access to a broad range of insulin products for less than $35 per month. Optum Rx – Formal answer to FTC complaint: https://www.ftc.gov/system/files/ftc_gov/pdf/611919.2024.10.09_optum_rxs_answer_to_complaint_0.pdf Optum has also argued publicly that drug manufacturers set insulin list prices and that its pharmacy-benefit business works to negotiate discounts and lower medication costs. Before the FTC complaint, Optum Rx announced in 2023 that it was moving eight insulin products to the preferred tier of its standard formularies, which it said would give consumers access to lower-cost options. Optum Rx – Actions to lower insulin costs: https://www.optum.com/en/newsroom/pharmacy-medications/optum-rx-takes-additional-steps-lower-cost-of-insulin.html Optum Rx has therefore not admitted the FTC's allegations, and the case should not be described as a finding that UnitedHealth or Optum illegally inflated insulin prices. There has also been an important recent development. The FTC reached settlements with Express Scripts in February 2026 and Caremark in July 2026 concerning the broader PBM case. On July 14, 2026, the FTC announced that its case against Optum had been withdrawn from adjudication so the Commission could consider a proposed consent agreement. As of August 2026, this means the Optum matter is moving toward a possible negotiated resolution, but the proposed agreement should not yet be described as a final Optum settlement. FTC – July 2026 update on Optum and PBM settlements: https://www.ftc.gov/news-events/news/press-releases/2026/07/ftc-secures-major-settlement-caremark-resolving-antitrust-case-against-second-drug-middleman Key facts: The FTC brought the case against UnitedHealth Group's Optum Rx in September 2024; Optum Rx was one of the three dominant PBMs accused of unfair and anticompetitive insulin rebate practices; the three PBMs collectively administer approximately 80% of U.S. prescriptions; the FTC alleges that their rebate structures favored high-list-price, highly rebated insulin and restricted access to lower-list-price alternatives; the FTC alleges that vulnerable patients sometimes paid more for insulin than the drug's entire net cost to the commercial payer after rebates; Optum Rx denies the allegations and says nearly all of its clients' members can access insulin for less than $35 per month; and in July 2026 the FTC withdrew the Optum case from adjudication while considering a proposed consent agreement. The case is significant for UnitedHealth Group because Optum Rx sits between drug manufacturers, health plans and patients and has substantial influence over formulary placement and pharmaceutical pricing incentives. However, unlike UnitedHealth's settled 2021 mental-health coverage case, the allegations against Optum Rx have not yet resulted in a final adverse finding or admission of wrongdoing. The evidence should therefore remain explicitly labelled as an FTC allegation unless and until the proposed Optum consent agreement becomes final.

In August 2021, United Behavioral Health and UnitedHealthcare Insurance agreed to pay $15.6 million and take corrective action following investigations and litigation by the U.S. Department of Labor and the New York Attorney General. Federal investigators found that, going back to at least 2013, the companies reduced reimbursement rates for out-of-network mental-health services, causing patients to pay more for treatment. Investigators also found that patients receiving mental-health care were flagged for additional utilization reviews, resulting in many payment denials. Of the total, approximately $13.6 million was designated for affected patients and beneficiaries, with another roughly $2 million in penalties. Because this was a settlement following government investigations—not merely an unresolved private allegation—it is particularly strong evidence. U.S. Department of Labor documentation: https://www.dol.gov/newsroom/releases/ebsa/ebsa20210812

The U.S. Department of Justice is conducting a criminal and civil investigation into UnitedHealth Group's Medicare Advantage billing practices. The investigation is examining whether the company improperly submitted diagnoses that increased Medicare payments from the federal government. UnitedHealth has stated that it is cooperating with the investigation and has denied any wrongdoing. In July 2025, UnitedHealth publicly confirmed that it had received criminal and civil requests from the Department of Justice relating to its Medicare Advantage business. Company statement: https://www.unitedhealthgroup.com/newsroom/2025/2025-07-24-uhg-responds-to-doj-investigation.html Reuters: https://www.reuters.com/legal/litigation/unitedhealth-complies-with-doj-criminal-civil-requests-filing-shows-2025-07-24/ Wall Street Journal: https://www.wsj.com/health/healthcare/unitedhealth-medicare-doj-diagnosis-investigation-66b9f1db

In November 2023, a federal class action lawsuit was filed against UnitedHealth Group alleging that its subsidiary, UnitedHealthcare (through naviHealth), used the AI tool nH Predict to help make coverage decisions for Medicare Advantage patients receiving post-acute care. The plaintiffs allege that the system resulted in premature denials of medically necessary care and that the company continued using it despite concerns about its accuracy. UnitedHealth has denied the allegations, and the litigation is ongoing. News: https://www.statnews.com/2023/11/14/unitedhealth-class-action-lawsuit-algorithm-medicare-advantage/ Court case: Estate of Gene B. Lokken et al. v. UnitedHealth Group, Inc. et al., U.S. District Court, District of Minnesota, Case No. 23-cv-3514.

The U.S. Securities and Exchange Commission brought a civil enforcement action directly against UnitedHealth Group Inc. over the company's historical accounting for backdated employee stock options. The SEC alleged that, from no later than April 1994 through 2005, UnitedHealth used hindsight to select advantageous grant dates for in-the-money options while creating records that indicated the grants had occurred on earlier dates. According to the SEC, UnitedHealth failed to record and disclose the resulting compensation expenses, producing materially misleading financial statements. The Commission said the backdated grants caused UnitedHealth to overstate net income during fiscal years 1994 through 2005 by as much as $1.526 billion and to conceal more than $1 billion in stock-option compensation. UnitedHealth agreed to settle charges that it violated federal securities-law reporting, books-and-records and internal-control provisions without admitting or denying the SEC's allegations. The SEC did not charge the company itself with fraud or seek a monetary penalty, citing UnitedHealth's extensive cooperation and remediation. Those measures included an independent investigation, new accounting controls, removal of certain executives and directors, and efforts that the SEC said recouped nearly $1.8 billion in cash, option value and other benefits from former and current officers. The federal court entered final judgment against UnitedHealth on March 10, 2009. Primary SEC enforcement release: https://www.sec.gov/newsroom/press-releases/2008-302-sec-files-settled-enforcement-actions-against-unitedhealth-group-former-general-counsel-stock SEC complaint: https://www.sec.gov/files/litigation/complaints/2008/comp20836-uhg.pdf The company settlement must be distinguished from the separate monetary penalties and officer-and-director bars imposed on individual former executives. This record concerns UnitedHealth Group's reporting, recordkeeping and internal-control violations as resolved through the SEC civil action.